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Examining the Upper Lip, Face and Profile

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Examining the Upper Lip, Face and Profile ISUOG Basic Training Examining the Upper Lip, Face & Profile Basic Training Learning objectives At the end of the lecture you will be able to: • Describe how to obtain the 3 planes required to assess the anatomy of the fetal face • Recognise the differences between the normal & most common abnormal ultrasound appearances of the 3 planes Basic Training Key questions 1. What are the key ultrasound features of plane 18 (upper lip)? 2. What are the key ultrasound features of plane 20 (profile)? 3. What probe movements are required to move from plane 18 (upper lip) to plane 20 (profile)? 4. Which abnormalities should be excluded after correct assessment of planes 18(upper lip),19 (orbits) & 20 (profile)? Basic Training The 20 + 2 planes Anatomical area Plane Description Overview 1 Sweep 1 Longitudinal head & body for initial orientation Spine 1 Sagittal complete spine with skin covering 2 Coronal complete spine 3 Coronal section of body Head 4 Transventricular plane* 5 Transthalamic plane* 6 Transcerebellar plane* Thorax 7 Lungs, 4 chamber view of heart 8 Left ventricular outflow tract (LVOT) 9 Right ventricular outflow tract (RVOT) & crossover of LVOT 10 3 vessel trachea (3VT) view of heart * measurement required Basic Training The 20 + 2 planes AnatomicalAnatomical area areaPlane PlaneDescriptionDescription AbdomenOverview 1 11 SweepTransverse 1 longitudinal section of headabdomen & body with for stomach initial orientation & umbilical vein* 12 Transverse section of abdomen at cord insertion Spine 13 1 Transversesagittal section(s) complete of left spine kidney with & pelvis,skin covering right kidney & pelvis Pelvis 14 2 Transversecoronal section complete of pelvis,spine bladder, both umbilical arteries 3 coronal section of body Limbs Head 15 4 Femur diaphysistransventricular length* plane* 16 5 3 bones oftransthalamic both legs, bothplane* feet & normal relationships to both legs 17 6 3 bones oftranscerebellar both arms, bothplane* hands & normal relationships to both arms Face Thorax 18 7 Coronal viewlungs, of upper4 chamber lip, noseview & of nostrils heart 19 8 Both orbits,left both ventricular lenses outflow tract (LVOT) 20 9 Median facialright profile ventricular outflow tract (RVOT) & crossover of LVOT Overview 2 Sweep 210 Transverse3 vesselsweep tracheaof body (3VT)from neck view to of sacrum, heart one vertebra at a time * measurement required Basic Training 20 + 2 planes abnormal appearances Plane Area Abnormal appearances (50+IUD) excluded by the correct 2+20 approach Sweep 1 Anencephaly, IUD 1-3 Spine Abnormal abdominal situs, left sided diaphragmatic hernia, meningocoele, Open spina bifida, sacral agenesis, sacral coccygeal teratoma, 4-6 Head Alobar holoprosencephaly, banana shaped cerebellum, cystic hygroma, large posterior fossa cyst, lemon shaped skull, occipital encephalocoele, skin oedema, ventriculomegaly 7-10 Thorax AVSD, CPAM, double aortic arch, ectopia cordis, overriding aorta, persistent left vena cava*, right aortic arch, severe aortic stenosis, coarctation & pulmonary stenosis, significant pericardial effusion (>4 mm) & pleural effusion (>4 mm), situs inversus/ambiguous, tetralogy of Fallot, transposition, univentricular heart 11-13 Abdomen Ascites, bilateral renal agenesis, duodenal atresia, echogenic bowel*, gastroschisis, omphalocoele, renal pelvic dilatation (>7mm AP), small/absent stomach 14 Pelvis Cystic renal dysplasia, lower urinary tract obstruction, 2 vessel cord 15-17 Limbs Fixed flexion deformities wrist, severe skeletal dysplasia (some), talipes 18-20 Face Anopthalmia, cataract*, cleft lip, proboscis*, severe micrognathia * optional, for local decision as to whether or not included Basic Training ISUOG guideline • Minimum evaluation of the fetal face should include an attempt to visualise the upper lip for possible cleft anomaly • If technically feasible, other facial features that can be assessed include the median facial profile, orbits, nose and nostrils Plane 18 (upper lip) Plane 20 (profile) Plane 19 (orbits) Practice guidelines for performance of the routine midtrimester scan (UOG 2011; 37:116-126) Basic Training Plane 18 (upper lip) – probe movements Plane 18 Plane Description 4 4 Transventricular plane 18 Slide 18 Coronal view of upper lip, nose & 0 0 19 nostrils Rotate 45 – 70 20 Both orbits, both lenses (Slide) Median facial profile From plane 4 to 18 - slide & rotate through 450-700 (& slide) Basic Training Plane 18 (upper lip) - probe movements • HC section, midline horizontal, slide • Orbits & cerebellum section, rotate 450 - 700 • Coronal section of face, slide to lips & nasal tip Basic Training What is an adequate section? 3 2 1 3 3 Practice guidelines for performance of the routine midtrimester scan, UOG 2011; 37:116-126 Fitzgerald M J & Fitzgerald M, Human Embryology, 1994, 168-173. Chudleigh T & Cook K, Cleft Lip & Palate: A Guide for Sonographers, prepared by CLAPA, 2001. Basic Training Plane 18 - probe movements Basic Training What is an adequate section? 1 3 Better for lip non diagnostic, – normal in this view no nose - angle for correct section Abnormaltoo far - referback - slide Practice guidelines for performance of the routine mid-trimester scan, UOG, 2011, 37:116-126/ Fitzgerald M J & Fitzgerald M, In Human Embryology,1994: 168-173.Chudleigh T & Cook K , Cleft Lip & Palate: A Guide for Sonographers, prepared by CLAPA, 2001. Basic Training Terminology & incidence • In the context of facial clefting, ‘lip’ may describe upper lip only or upper lip & alveolar ridge/alveolus • Overall incidence of cleft lip & palate malformations (live births) in Europe ~1:700. Similar to that of Down’s syndrome & talipes • Isolated cleft lip (+/- alveolar ridge) 25% • Cleft lip, alveolar ridge & palate, of varying degrees, 35% – 25% unilateral – 10% bilateral • Isolated cleft palate 40% Basic Training Normal or abnormal? Unilateral Unilateral Normal Bilateral Unilateral Basic Training Plane 19 (orbits) - probe movements Plane 19 4 Slide Plane Description Rotate 19 4 Transventricular plane 18 Coronal view of upper lip, nose & nostrils 19 Both orbits, both lenses 20 Median facial profile From plane 4 to 19 – slide (rotate minimally [dip for OP]) Basic Training Plane 19 (orbits) - probe movements • HC section, midline horizontal → slide • Orbits & cerebellum section → rotate towards neck minimally • Section will be ~OT → dip (~900) for OP section Basic Training What is an adequate section? 1 Upper orbit & lens – good, Good – both orbits & lenses clearly seen Lower orbit present, lens? Practice guidelines for performance of the routine midtrimester scan, UOG, 2011, 37:116-126) Basic Training Normal or abnormal? 1 Size discrepancy of orbits - abnormal* ?Normal ? nondiagnostic (?ventricles) - Section good enough to confirm Refer appearances normal? Basic Training Plane 20 (profile) – probe movements Plane 20 4 Slide Plane Description Angle through 900 4 Transventricular plane 20 18 Coronal view of upper lip, nose & nostrils (Rotate [minimal]) 19 Both orbits, both lenses 20 Median facial profile From plane 4 to 20 - slide, angle through 900 (& [minimal] rotation) Basic Training Plane 20 (profile) - probe movements • HC section, midline horizontal, slide • Angle probe through 900 to produce mid-sagittal section • Minimal rotation of probe to acquire correct section Basic Training What is an adequate section? Incorrect section, para-sagittal Incorrect section or abnormal? - Slide (minimally) ?Chin - slight rotation Basic Training What is an adequate section? Acceptable - normal Basic Training What is an adequate section? Basic Training Normal or abnormal? Normal Abnormal - refer Abnormal - refer ?Normal Abnormal - refer Normal ?Section correct - (normal) Lip of above Basic Training Key points 1. Imaging the upper lip correctly is important as facial clefting has a birth incidence similar to Down’s syndrome & talipes. 2. Evaluation of the orbits & lenses can be performed from an occiput transverse position, providing that the lower orbit & lens are adequately imaged. 3. Orbital anomalies & detectable abnormalities of the lens are rare. Basic Training Key points 4. The most common reason for incorrectly suspecting micrognathia in a normal fetus is failing to appreciate that the section obtained is oblique, rather than truly mid-sagittal. False positives decrease with experience. 5. If you are unable to confirm the normal appearance of all the structures in planes 18-20, the woman should be referred for a more detailed examination. 6. Practice, performed correctly, makes perfect. Basic Training ISUOG Basic Training by ISUOG is licensed under a Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International License. Based on a work at https://www.isuog.org/education/basic-training.html. Permissions beyond the scope of this license may be available at https://www.isuog.org/ BasicBASICEditable Training TRAINING text here.
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